Healthcare Provider Details

I. General information

NPI: 1750296539
Provider Name (Legal Business Name): LAITH ELISSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 UNIVERSITY BLVD W
JACKSONVILLE FL
32217-2130
US

IV. Provider business mailing address

3505 UNIVERSITY BLVD W
JACKSONVILLE FL
32217-2130
US

V. Phone/Fax

Practice location:
  • Phone: 904-636-0779
  • Fax:
Mailing address:
  • Phone: 904-636-0779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS70974
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: